2Housing as a determinant of health: what does this mean for the EHP? Dr Stephen BattersbyPresident, CIEH
3Number of people killed or injured by location Per yearUKFranceKilledInjuredAt work3801,500,0007001,150,000On the road3,600317,0007,600170,000At home4,1002,700,0009,0003,000,000Source: WHO Europe 2005
4Source: Dahlgren G and Whitehead M (1991) Policies and strategies to promote social equity in health. Stockholm, Institute for Futures Studies
5A health map for the local human habitat Source: Barton H & Marcus Grant M, 2006, JRSPH, 126 (6)
6Marmot Review: Social determinants of health The conditions in which people are born, grow, live, work and age, including the health system (environmental health is part of the health system)These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.
7Social determinants of health Social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countriesPersisting inequalities across key domains provide ample explanation: inequalities in early child development and education, employment and working conditions, house and neighbourhood conditions.
8Marmot Review Policy Recommendations Improve the availability of good quality open and green spaces across the social gradientImproving energy efficiency of housing across the social gradientIntegrate the planning, transport, housing, environmental and health systems to address the social determinants of health in each locality.
10Housing and health inequity In 2009, 41% of the PRS was “non-decent” (English Housing Survey Headline Report 2009/10)33% of households living in poverty were living in non-decent homes94% LAA areas prioritised new and/or affordable housing targets but <1/3 prioritised targets for the existing stock (Audit Commission, 2009)
11Laying the Foundations – a housing strategy for England Well at least a government has published a housing strategyDoes not obviously recognize what Marmot and other have been sayingOn the PRS it is a missed opportunity – it is complacent – more than 500,000 private tenants unhappy with their landlord & more than 1 million unhappy with how they deal with repairs
12DampnessDampness is more likely to occur in houses that are overcrowded and lack appropriate heating, ventilation and insulation (Institute of Medicine 2004), the prevalence of indoor damp in low-income communities can be substantially higher than the national average WHO Guidelines for Indoor Air Quality - Dampness and Mould, WHO, 2009
13Dampness In 2009 895,000 dwellings had condensation 701,000 had penetrating damp651,000 had rising dampPRS more likely to have damp problems, but unlikely that more than ≈100,000 within whole housing stock have Category 1 hazard for damp and mould – although impact on mental health also
22Impact of poor housingCIEH/FoE work shows 20% of the 3.4 million households in PRS are in fuel povertyIllness due to cold housing cost the NHS at least £145 million p.a. (BRE estimates dealing with homes with SAP<41 would save NHS £700m p.a.)BRE has shown that Category 1 hazards cost NHS in England £600million a year and costs to society at least £1.5bn p.a.
23Mental health impacts of housing Poor mental health – overcrowding leads to behavioural difficulties and poor educational attainment & is associated with poor mental health and wellbeing and psychological stressFuel poverty and affordability (debt) adversely affects mental healthGreen space (place and external environment) can impact positively on mental healthLack of security has negative impactHousing can impact on resilience in extreme weather events
24Non-decent homes by tenure and criteria (000s dwellings)Minimum Standard HHSRSThermal comfortRepairModern facilitiesAll non-decentOwner/occ3,1061,4188253654,377Private Rented9716033381631,465LA243149118491HA1911477445389All Tenures4,5112,3171,3566916,722Source: EHS Headline report , CLG
25Activity in perspective EHS 2009, 4.7 million (21% of) dwellings had one or more Category 1 hazards & 971,000 in the PRS - average of 2,969 per LHA.FoI requests to LHAs by Karen Buck MP found in 2009/10 an average of about 273 dwellings with hazards dealt with per LHA (primarily “informally”)Dampness more frequently dealt with than excess cold – implication that most activity complaint led not necessarily the worst conditions or most vulnerable households
26Activity in perspective Some LHAs are not using the powers availableMany do not have easily accessed records of hazards dealt with (≈ 42% in 2009/10)How do you use CIEH Cost Calculator or other means to demonstrate health impact of interventions?At least 25% had not serve an improvement notice in three years and >50% had not served a hazard awareness notice
27LHA.s and unhealthy housing- implications Do private sector housing strategies truly reflect conditions and needs? Reported use of Part 1 of the 2004 Act appears to indicate not.Changes to welfare benefits (HB), duties on homelessness and proposals on security of tenure indicate need for better oversight of PRS as there will be greater opportunities for the irresponsible landlordsBetter use of powers needed nowThe figures for 2006/07 do not include data relating to upgrading of HMOs via the licensing regime and other powers to deal with HMOsAccording to CLG LHAs had granted 21,696 licences for HMOs by July 2009 and rejected 107 applications, and have received over 30,000 applications for HMO licences. Building Research Establishment estimates that 56,000 of the 236,000 to 379,000 HMOs in England are subject to mandatory licensing -35,000 (63%) still unlicensed over three years after the provisions came into force.
28Action on unhealthy housing Then what about poorer owner-occupiers?CLG cuts to PS Renewal budget don’t help - £0 in 2011/12Duty under s.4 of Act to inspect (tenure not an issue). How is this being met and how can it be met in current circumstances?
29Action on unhealthy housing Complaint (Demand) led only is not the best wayWho makes the referrals to LHA.s for intervention? – role for health and advice agencies - GPs, HACs etcLHA.s deal with damp more often than Excess Cold (1.8 million where Category1 hazard)Apparent that coherent housing and health strategies the exception rather than the rule
30Challenges for EH Profession Cold homes and cold related ill-health – the greatest risk in the housing stockUnintentional injuries more likely in cold homes and also those in noisy environments (sleep disturbance)Educational attainment is lower for children brought up in housing that is overcrowded or in poor condition – reinforcing inequalitiesHow well have EHPs advocated for better use of the available tools?
31Action to help reduce health inequalities Better collection, analysis and used of data required to develop more effective housing and health strategiesPart 1 of the 2004 Act should be used more strategically to reduce risks to health and safety from housing conditions - so far a missed opportunityCloser working with other health professionals (who could also advocate for those living in poor accommodation) needed
32ConclusionEHPs can play an important part in addressing health inequalitiesThey could intervene to greater effect to reduce the negative impact of poor housing and reduce one of the stressors that leads to health inequalities – they will need to if responsible landlords move “up-market”Reasons can always be found for no or weak action but can that be right? Does the situation not demand innovation & making better use of the tools available?